Course/Unit Completion Report
CPE Supervisor will Complete a Report within 30 Days of End of Course/Unit
Start Date of Course
End Date of Course
Student Membership #
CPE Center (Select One)
#1001-Univ. of KS Med. Center
#1003B-Arkansas Children's NW
#1012-Spiritual Care Center
#1013-Hospice Chaplaincy Resource Center
#1014-Baton Rouge General Medical Center
#1015-Spiritual Living Center for Ed and Training
#1016-On Track Clinical Training and Supervision
#1017-Charles E. Smith Life Communities
#1018-A Balanced Presence
#1019-Hamilton Health Care Systems
Student Completed the Course/Unit
Student Withdrew (See Below-Required).
Student was Dismissed (See Below- Required)
Briefly Describe the Reason the Student Withdrew or Was Dismissed.
No Credit-Student Withdrew or was Dismissed (See Below-Required)
CPE 500 (Specialization)
SEC 1000 (Training Supervisor Module)
No Grade Awarded for Students Who Withdrew or Dismissed
Exemplary (95-100) Supervisory Candidate I
Competent (90-94) Supervisory Candidate I
Developing (80-89) Supervisory Candidate I
CEU Credit (10.0 is the Standard for 100 hours. If CEU Credit is provided outside this please indicate the reason below).
No CEU Credit-Student Withdrew or was Dismissed
5.0 (50 Contact Hours) 1/2 CPE Course/Unit
10.0 (100 Contact Hours) 1 CPE Course/Unit
Please describe the reason for granting something other than 10.0 (100 Contact Hours).
Student is currently employed in a ministry position other than chaplaincy.
Student obtained employment as a chaplain as a result of CPE.
Should be Empty: